Health care providers across the nation are experiencing a crisis in nurse staffing, and we are standing on the precipice of an unprecedented nursing shortage. ANA is pleased that the advisory council has acted to gather information and encourage cooperation on nursing workforce issues. Certainly, the current and emerging shortage of registered nurses (RNs) poses a real threat to the nation's health care system. RNs are the largest single group of health care professionals in the United States. Concerns that we have all been hearing about the current nursing shortage underscore the fact that having a sufficient number of qualified nurses is critical to the nation's health care system.

The emerging nursing shortage is very real and very different from any experienced in the past. This new shortage is evidenced by fewer nurses entering the workforce; acute nursing shortages in certain geographic areas; and a shortage of nurses adequately prepared to meet certain areas of patient need in a changing health care environment. In addition, projections show that the current shortages are just a minor indication of the systemic shortages that will soon confront our health care delivery system.

It is important to realize that the causes, and therefore the answers, for the nursing shortage are complex and interrelated. It is critical to examine issues in education, health delivery systems and the work environment. There is no single cure to what ails nursing.

Recent Changes in Nurse Employment

Current staffing problems are inexorably tied to changes in nurse employment practices over the last decade. Just ten years ago we were emerging from the nursing shortage of the 1980s. Nursing workforce issues had caught the attention of the highest reaches of the Reagan and Bush Administrations and the HHS Secretary's Commission on Nursing had recently released their recommendations. Providers across the nation instituted aggressive recruitment campaigns and wages were increased. In fact, average RN wages increased by $4 an hour in the decade between 1983 and 1993 (in constant 1997 dollars). The Division of Nursing's national sample survey shows that the real average annual salary of all RNS employed full-time rose from $17,398 in 1980 to $23,166 in 1992 (in constant 1984 dollars). At the same time, RN employment in hospitals grew by a steady rate of 2-3 percent annually through the 1980's and early 90's. Employment in home health also showed impressive growth.

However, in the mid-1990's the picture changed. During this time, managed care began to exert downward pressure on provider margins. In addition, the impact of the change in Medicare reimbursement to prospective payment was taking hold. Providers eagerly sought out and implemented programs designed to reduce expenditures. New models of health care delivery were implemented, and highly-trained, experienced - and therefore higher paid - personnel were eliminated or redeployed. As RNs typically represent the largest single expenditure for hospitals (averaging 20 percent of the budget) we were some of the first to feel the pinch. Lesser-skilled, lower-salaried assistive staff were hired as replacements and RN salaries decreased in both actual and real terms.

Analysis of census data shows that between 1994 and 1997, RN wages across all employment settings dropped by an average of 1.5 percent per year (in constant 1997 dollars). Between 1993 and 1997, the average wage of an RN employed in a hospital dropped by roughly a dollar an hour (in real terms). RN employment in the hospital sector reversed to the negative, dropping most precipitously in areas of the county that experience high managed care saturation. Many providers eliminated positions for nursing middle managers and executive level staff. Hospital employment for nurses aides, however, increased by an average of 4.5 percent a year between 1994 and 1997.

ANA challenged the safety and efficacy of using unlicenced personnel to deliver care to a patient population that was more acutely ill on admission, that required more technically sophisticated care, and whose length of stay was significantly decreased. In the majority of cases our calls went unheeded.

The overall impact of the changes in the 1990s was to increase pressure on staff nurses who were required to oversee unlicenced aides while caring for a larger number of sicker patients. The elimination of management positions decimated the career ladder and decreased the support, advocacy and resources necessary to ensure that nurses could provide optimum care. At the same time employment security was uncertain and wages were being cut.

The Current Employment Situation

Not surprisingly, the changes in the RN employment environment in the last decade have resulted in a downturn in the number of people working in the nursing profession, and growing discontent among those who remain. Enrollments in four-year nursing schools have dropped by approximately 5 percent per year over the last 6 consecutive years. As the image of professional nursing has changed from a field that offered many opportunities and high job security to one that holds great uncertainty, low starting wages and difficult working conditions, student have shied away from nursing programs.

A recent survey of ANA members revealed that nearly 55 percent of the nurses surveyed would not recommend the nursing profession as a career for their children or friends. In fact, 23 percent of the respondents indicated that they would actively discourage someone close to them from entering the nursing profession.

At the same time, an alarming number of existing RNS are choosing not to work in nursing. The 2000 national sample survey of registered nurses shows that a record number of nurses (500,000 nurses - more than 18 percent of the nurse workforce) who have active licenses are not working in nursing. Another national survey commissioned by the Federation of Nurses and Health Professionals reports that 50 percent of all nurses have recently considered leaving direct care positions for reasons other than retirement. Clearly, something in the practice setting is driving these people away from their chosen field.

The Environment of Care

In an effort to ascertain the cause of nurse discontent, ANA recently conducted an on-line survey of nurses across the nation. Nearly 7,300 nurses took the opportunity to express their opinions about their working conditions. The majority (70 percent) of the respondents work in hospitals or acute care facilities, 50 percent were staff nurses. These nurses report that over the last two years they have experienced increased patient loads, increased floating between departments, decreased support services and increasing demands for mandatory overtime.

The vast majority (75 percent) reported that they believe that the quality of nursing care in their work setting has declined over the last two years. In fact, more than 40 percent of the nurses reported the quality of care in their facility has declined to a level that they would not feel confident having someone close to them receive care there. The first reason given for the decline in the quality of care was inadequate staffing.

As is the case nationally, many respondents (700) reported that they are not currently working in nursing. The top reason given for leaving the nursing field was to find a more rewarding position. Clearly, something must be done to improve the environment in which nurses work. No matter how many resources are placed into increasing educational opportunities for nurses, the nursing shortage will remain and likely worsen if changes in the workplace are not enacted. ANA maintains that the best way to do this is to provide our nurses with the support that they need to provide high quality care.

The profession of nursing will be unable to compete with the myriad of other career opportunities available in today's economy unless we improve working conditions. Registered nurses, hospital administrators, other health care providers, health system planners, and consumers must come together in a meaningful way to create a system that supports quality patient care, and all health care providers.

Federal Support for Nursing Programs

In addition to addressing workplace issues, ANA is actively working to strengthen nurse education. We have long supported federal funding for programs designed to strengthen the nurse education infrastructure. We regularly meet with Members of Congress, provide testimony and recommendations to the Appropriations Committees and work with our fellow nursing organizations to support the nurse education programs administered through Titles VII and VIII of the Public Health Service Act. ANA has redoubled its efforts this year to ensure that an adequate funding source is provided.

Along with the Tri-Council for Nursing, ANA is urging Members of Congress to increase funding for the programs of the Nurse Education Act by at least $25 million to $103.7 million. Due to the growing shortage of nurses, we are also advocating an increase in funding for the nurse education loan repayment program (Section 846 of the Public Health Service Act). We are recommending that funding for the Nurse Education Loan Repayment Program for FY2002 be increased to at least $10 million.

Improvements to Title VIII

In addition to the activities that we are undertaking to secure adequate funding for existing NEA Title VIII programs, ANA is beginning efforts to expand and improve Title VIII. As you are well aware, the programs of the Nurse Education Act are due to be reauthorized in 2002. In addition, ANA is working with a number of Members of Congress to support new programs within Title VIII to address specific nurse workforce challenges. ANA is committed to enacting and supporting programs designed to attract more students into nursing, ensuring that the schools of nursing will be able to provide faculty and updated curricula to support them, recruiting a more diverse student population to serve an increasingly diverse patient population, providing assistance to students to enable them to complete nursing studies, and assuring collection and analysis of nursing workforce data to guide appropriate implementation of the programs.

The current legislative authority for the programs of the Nurse Education Act was implemented by the Health Professions Partnership Act of 1998 (P.L. 105-392). As I discussed earlier, the mid- 1990's were a time of rapid changes in health care delivery. Nurses in acute care settings were being replaced by unlicenced assistive personnel, and the locus of health care delivery was rapidly moving into community-based settings. ANA and the Division of Nursing recognized that advanced practice registered nurses are uniquely qualified to meet the growing demand for decentralized primary care. For these reasons, ANA supported this legislation that consolidated existing programs to support nurse education in order to improve access to and quality of health care in underserved areas, and to provide administrative flexibility and simplification.

The Health Professional Partnership Act of 1998 also removed the old line-item appropriation for nurse education programs. In its place, the NEA was divided into three major areas: advanced practice nursing education, basic nurse education and practice, and workforce diversity. Congress also enacted a ‘hold harmless' provision that directed the Division of Nursing to maintain a generous, proportional set-aside of all NEA funding for the advanced practice nurse education programs. In practice, this means that more than 77 percent of all of the funding allocated for the Nurse Education Act must be spent on advanced practice.

While ANA feels that it is critical to maintain the current advanced practice nurse programs supported by the NEA, we feel that it is important to provide the Division of Nursing the flexibility to target resources to areas that are experiencing the greatest need. Therefore, ANA supports the elimination of this hold harmless provision. As the health care system is changing around us, and the needs of the nursing workforce are evolving to address those changes, we believe that it is important to be able to focuses resources to address emerging challenges.

New areas of concentration could include efforts to attract more nurses into faculty positions and an increased emphasis on diversity programs. In addition, ANA is interested in exploring methods to open up federal support for educational opportunities to nursing students who attend classes on a part-time basis. We know that many nursing students must juggle the demands of a job and family obligations at the same time that they are attending classes. We would like to ensure that these responsibilities do not preclude committed students from receiving assistance through federal programs.

Data Collection

ANA is also supporting enhanced reporting and collection of nurse workforce and nurse staffing data. The current four-year cycle of the national sample survey of registered nurses can not provide data in a timely fashion. Policymakers, educators, and health care providers would all benefit from a two-year rather than a four year cycle.

In addition, ANA is concerned about the complete lack of a regular reporting system on nurse staffing practices. The absence of any standardized, mandatory public reporting that can objectively quantify trends in staffing practices has allowed massive changes in staffing methodologies to go unchecked. The Federation of Nurses and Health Professional's survey reports that 66 percent of all current nurses see staffing levels as a major problem. Dramatic changes in staffing have a direct impact on health outcomes and the quality of work life for nurses and other health care workers - yet no one is monitoring them.

This absence of staffing data has complicated efforts to develop reliable staffing requirements. As you are aware, many organizations have recently undertaken efforts to identify minimum staffing levels below which patient care is jeopardized. The Health Care Financing Administration has tentatively identified such levels for long term care facilities. Today policymakers in the state of California are embroiled in efforts to enact legislation that requires minimum nurse staffing levels in acute care facilities. According to the National Conference of State Legislators, 21 states identified "nurse staffing ratios in hospitals" as a legislative priority in 2000. ANA expects to see a number of states move forward on these proposals this year. Still, there is no entity equipped to collect the data needed to support and evaluate these staffing programs. Therefore, ANA is pursuing efforts to require providers to publically disclose and report to the federal government uniform information on their nurse staffing levels on a department-by-department and shift-by-shift basis.

Conclusion

ANA is vitally interested in the work that this advisory commission is undertaking to ensure an adequately prepared and adequately supported nursing workforce to care for our nation. We are committed to working with you and our colleagues in the health care community to support programs that will help us meet this important goal. We realize that there must be a multi-facet approach to the emerging nurse shortage, and we look forward to working with you to develop and implement an appropriate agenda.

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